Healthcare Provider Details

I. General information

NPI: 1003052705
Provider Name (Legal Business Name): MRS. PRISCILLA SARAH INGRUM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2008
Last Update Date: 12/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1909 HAMPSHIRE PIKE
COLUMBIA TN
38401-5650
US

IV. Provider business mailing address

6423 YEATMAN LN
COLUMBIA TN
38401-7931
US

V. Phone/Fax

Practice location:
  • Phone: 931-388-5757
  • Fax:
Mailing address:
  • Phone: 615-310-4824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: